=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578798195
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARGIE J WESLEY DOM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2009
-----------------------------------------------------
Last Update Date | 09/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7801 ACADEMY NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-503-0308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6237 VANCE RD STE 4
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37421-2954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-596-9024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 997
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------